Provider Demographics
NPI:1437576840
Name:ROBINSON, JORDAN (PHD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:
Last Name:ROBINSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 BALSAM TRL E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1706
Mailing Address - Country:US
Mailing Address - Phone:517-614-3697
Mailing Address - Fax:
Practice Address - Street 1:3209 W 76TH ST STE 207
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5246
Practice Address - Country:US
Practice Address - Phone:517-614-3697
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP6051103G00000X
KS2198103G00000X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103T00000XBehavioral Health & Social Service ProvidersPsychologist